<include file="./Application/Member/View/Public/header.html" />
<div class="well invoice">
<div class="navbar" style="padding:15px;">
            <div class="navbar-inner">
            <form action="#" method="post">
              <h6>
              姓名{走访人姓名}<input type="text" value="{$name}" name="name" style="margin-left:5px;"><br/>
             手机号{可不填}<input type="text" value="{$phone}" name="phone" style="margin-left:5px;"><br/>
              </h6>
              <a class="btn btn-success pull-right" type="button" href="{:U('Admin/Recipients/apply')}">返回</a>
          
            </div>
          </div>
                    <div class="invoice-head">
                       <p style="padding-bottom:5px;font-size:14px;">走访({$apply_name})核实的实际信息</p>
                        <textarea name="content" id="" cols="60" rows="10"></textarea>
                    </div>
                    
                    <div class="row-fluid">
                        
                       <a href="javascript:;" class="btn btn-success pull-left vlRequest-sub">提交</a> 
                  
                  </div>
                   <input type="hidden" value="<?php echo $_GET['id'];  ?>" name="applyid">
                    <script type="text/javascript">
                    $('.vlRequest-sub').click(function(event) {
                      $('form').submit();
                    });
                    </script>
                 </form> 
                    
               
                    </div>

                    
              

              </div>
 <include file="Public/footer" />